Employment Application

Employment Application Form:
Personal Information:
Full Name*

PrefixFirst NameMiddle NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Birth Date*

MonthDayYear
Are you a U.S. Citizen?*

YesNo
Have you ever been convicted of a felony or misdemeanor?*

YesNo
Do you have a Driver's License*

YesNo
Do you have Professional Liability Insurance?*

YesNo
Are you currently licensed? If so, please list what license you currently hold and which state(s) it is held in. *
How were you referred to us?*

IndeedFacebookLinkedInEmployeeWalk-InOther
Employment Desired:
Position applying for*
Date You Can Start*

MonthDayYear
Which office are you interested in*

MaconHiramAlpharettaOther
Employment Desired*

Full TimePart Time
Salary Desired
Amount in $
Expected Hourly Rate*
Amount in $
Have you worked here before?*

YesNo
Have you applied here before?*

YesNo

What is your current availability? (State all the hours you are available to work in the chart below.)*

Rows	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
From
To

Are you available to see clients during evenings and weekends, as these times are often requested in our private practice setting?*
Please list 2-3 dates and time ranges that you could do an interview. *
Education:
High School*
Name of High School Attended
Number of Years Attended
Graduated?*

YesNoOther
College*
Name of College/University Attended
Number of Years Attended
Graduated?*

YesNoOther
Area of Study/Degree*
Graduate School*
Name of Graduate School Attended
Number of Years Attended
Graduated?*

YesNoOther
Area of Study/Degree*
Trade School/Other
Name of Trade/Technical/Other School Attended
Number of Years Attended
Graduated?

YesNoOther
Area of Study/Degree
Skills/Qualifications:
Describe your skills. What makes you a good fit for this position and what clinical expertise do you bring to this position? *
List any relevant skills
What is your ideal caseload? In terms of number of clients, demographics, presenting concerns, etc.*
Tell us about your personality. How would colleagues describe you?*
Please describe your therapeutic orientation.*
Please describe your approach towards providing culturally responsive, LGBTQ+ affirming, gender-affirming care.*
What are you passionate about?*
Please share one (or multiple) fun fact(s) about you.*
Training or Certifications
List any relevant certifications or qualifications
What other skills or experience do you have outside of the clinical space that you feel may be beneficial to our practice?
Current Employment:
Current Employer*
Name of Current Employer or NONE if not Employed
Position*
Salary
Reason for Leaving?
Start Date*

MonthDayYear
May We Contact?*

YesNo
Type of work performed*
Supervisor name and position*
Previous Employment:
Previous Employer*
Name of Previous Employer
Position*
Salary
Reason for Leaving?*
Start Date*

MonthDayYear
End Date*

MonthDayYear
May We Contact?*

YesNo
Type of work performed*
Supervisor name and position*
Previous Employer
Name of Previous Employer
Position
Salary
Reason for Leaving?
Start Date

MonthDayYear
End Date

MonthDayYear
May We Contact?

YesNo
Type of work performed
Supervisor name and position
References:

Please list three (3) references that are familiar with your work.
Reference 1*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email*
Reference 2*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email*
Reference 3*
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email*
Cover Letter & Resume (Optional):
Cover Letter*

Upload a File

Cancelof
Resume*

Upload a File

Cancelof
Send Application:
By clicking the submit button below, I cerity that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employement may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compenstation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.
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Employment Application Form:

Personal Information:

Employment Desired:

Education:

Skills/Qualifications:

Current Employment:

Previous Employment:

References:

Cover Letter & Resume (Optional):

Send Application: